Nursing Investigation Results -

Pennsylvania Department of Health
FAIR ACRES GERIATRIC CENTER
Patient Care Inspection Results

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FAIR ACRES GERIATRIC CENTER
Inspection Results For:

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FAIR ACRES GERIATRIC CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, State Licensure Survey and an Abbreviated survey in response to a complaint, completed on March 11, 2021, it was determined that Fair Acres Geriatric Center, was not in compliance with the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.






 Plan of Correction:


483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:


Based on observation, review of clinical records, facility policies and procedures, and interviews with staff, it was determined that the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice by failing to follow bowel management protocol for one of 40 residents reviewed (Resident R327)

Findings include:

Review of facility documentation revealed a policy, "Bowel Protocol," approved in February 2020, stating residents without bowel movement for six shifts "need to be evaluated/medicated for potential constipation or fecal impaction" and "offer/give PRN (as needed) laxative, if no results from first dose in 24 hours perform a bowel evaluation and administer second dose of Milk of Magnesia (MOM) as ordered laxative unless signs and symptoms of bowel obstruction. If no results from second dose of ordered MOM in 24 hours perform a bowel evaluation and administer Fleets enema."

Further review of facility policy, "Bowel Protocol," revealed "if signs and symptoms of bowel obstruction, do not administer a laxative and notify the physician immediately" and "notify physician of resident with repeated abnormal stool."

Further review of facility policy revealed symptoms of bowel obstruction include but not limited to "nausea/vomiting."

Review of clinical documentation for Resident R327 revealed an active physician order with a start of May 27, 2020, for Milk of Magnesia (laxative), give 30 ml via g-tube every 24 hours as needed for constipation.

Further review of clinical documentation for Resident R327 revealed an active physician order with a start date of May 27, 2020, for "Enema Ready (used to relieve constipation), use per rectally daily as needed for constipation".

Review of clinical documentation for Resident R327 revealed a Minimum Data Set (MDS) dated January 27, 2021, revealed Resident R327 is total dependence for toilet use.

Further review of clinical documentation for Resident R327 revealed a Minimum Data Set (MDS) dated January 27, 2021, revealed Resident R327 has a Brief Interview for Mental Status (BIMS) of 14 indicating cognition is intact.

Review of clinical documentation for Resident R327 revealed a Bowel and Bladder report revealed resident had a small bowel movement on March 4, 2021.

Further review of clinical documentation for resident R327 revealed resident did not have any bowel movements from March 4, 2021, at 4:12 a.m. until March 11, 2021.

Review of Medication Administration Record (MAR) revealed Resident R327 received one dose of Milk of Magnesia 30ml as ordered on March 6, 2021, at 1:04 p.m.

Further review of MAR failed to reveal any additional doses bowel protocol medications had been administered to Resident R327 between March 6, 2021, and March 11, 2021.

Observation of Resident R327 on March 9, 2021, in the presence of licensed employee E3 revealed resident had vomit on his bed and in his trash can.

Observation of Resident R327 on March 10, 2021, at 12:37 p.m. reviewed small amount of vomit in his trash can.

Interview with Resident R327 on March 10, 2021, at 12:38 p.m. resident confirmed he vomited once into his trash can.

Interview with Employee E4 on March 10, 2021, at 12:40 p.m. confirmed vomit was in the trashcan.

Review of clinical documentation on March 11, 2021, at 11:00 a.m. failed to reveal notification to physician about Resident R327 without bowel movement in five days or the two episodes of vomiting.

Interview with the Assistance Director of Nursing on March 11, 2021, at 12:40 p.m. confirmed facility bowel protocol was not followed for Resident R327.

28 Pa. Code 211.10(c) Resident care policies

28 Pa. Code 211.12(d)(1) Nursing services

28 Pa. Code 211.12(d)(5) Nursing services







 Plan of Correction - To be completed: 05/03/2021

Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

All residents meeting the criteria for implementation of Bowel Protocol have the potential to be affected.

A bowel assessment was conducted for Resident 327 and was continued daily x 72 hours. Physician made aware, administering nurses were educated.

Bowel Protocol policy was reviewed and revised as needed. In-services were provided to appropriate staff immediately.

Facility wide education initiated for professional nurses administering medications.

DON, or designee, will audit for appropriate implementation and adherence to Bowel Protocol. Audits will occur daily x2 weeks, weekly x2 and monthly x2, on all shifts. If trends are identified, corrective action, including a Root Cause Analysis, will be reported to the QA Committee.

483.45(d)(1)-(6) REQUIREMENT Drug Regimen is Free from Unnecessary Drugs:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.45(d) Unnecessary Drugs-General.
Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-

483.45(d)(1) In excessive dose (including duplicate drug therapy); or

483.45(d)(2) For excessive duration; or

483.45(d)(3) Without adequate monitoring; or

483.45(d)(4) Without adequate indications for its use; or

483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or

483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.
Observations:


Based on a review of the facility's policy, clinical record review, resident interview and staff interview, it was determined that the facility failed to ensure that narcotic pain medications were administered with adequate indications for use for one of 35 residents reviewed (Resident 54).

Findings include:

A review of the facility policy titled, "Pain Management," with an approval date of February 2020, it was revealed that a physician's orders for pain medication must specify PRN (As needed) pain medication along with corresponding pain scale. Pain scale to be used: 0- no pain, 1-3 = mild pain, 4-6 = moderate pain, 7-10 = severe pain. A separate pain evaluation is to be completed with the A.M. and P.M medication pass and once on 11-7 if the resident is awake. Ask the resident if they are experiencing pain, or observe for non-verbal signs of pain, use pain evaluation scales. If the answer is yes, utilize scale, assign a number value for pain intensity.

A review of Resident 53's diagnoses list revealed Chronic Pain, Neuropathy (Occurs due to damage in the nervous system), Spinal Stenosis (An abnormal narrowing of the spinal canal that results in pressure on the spinal cord), and Lumbar Spondylosis (The degeneration of the vertebral column from any cause).

A review of Resident 53's Quarterly Minimum Data Set (MDS- An assessment tool used to facilitate the management of care) dated December 15, 2020, revealed that the resident was cognitively intact.

An interview with Resident 53 on March 10, 2021, at 8:30 a.m. revealed that she/he had periods of generalized pain but denied any pain during the interview.

A review of Resident 53's Physician's Order Sheet (POS) revealed an order on January 10, 2021, for Oxycodone (A narcotic medication used to treat moderate to severe pain) five mg tablet, take one tablet by mouth every six hours as needed for moderate pain (Pain scale of 4-6). The resident also had an order for gabapentin (A medication used to treat nerve pain) 200 mg one capsule three times a day.

A review of Resident 53's January 2021 Medication Administration Record (MAR) revealed that the PRN oxycodone was administered to Resident 53 with a pain scale of zero (no pain) on January 17, 2021, at 10:08 a.m., January 23, 2021, at 12:49 p.m., and January 29, 2021, at 5:26 p.m.

A review of the February 2021 MAR revealed that the PRN oxycodone was administered to Resident 53 with a pain scale of zero (no pain) on February 3, 2021, at 8:23 a.m., February 5, 2021, at 11:56 a.m., February 7, 2021, at 7:21 p.m., February 9, 2021, at 3:32 a.m., and February 19, 2021, at 9:05 a.m.

A review of the March 2021 MAR revealed that the PRN oxycodone was administered to Resident 53 with a pain scale of zero (no pain) on March 1, 2021, at 9:53 a.m., March 4, 2021, at 10:46 a.m., and 7:26 p.m., March 5, 2021, at 8:45 a.m., and March 10, 2021, at 4:35 p.m.

An interview with licensed nurse Employee E6 on March 11, 2021, at 9:00 a.m. revealed that before administering PRN pain medications, the nurse will assess the resident's pain which includes intensity, The pain scale will be completed and the ordered PRN medication will be administered for moderate pain. Employee E6 was unable to provide an answer as to why a PRN oxycodone was administered for a pain scale of zero on the dates mentioned above.

An interview with the Unit Manager Employee E7 on March 11, 2021, at 9:15 a.m. revealed that the pain scale for moderate pain was four, five, and six. Employee E7 confirmed that Resident 53 should have not administered with PRN oxycodone for a pain scale of zero.

The facility failed to ensure that Resident 53 was administered with PRN oxycodone as indicated for use (moderate pain).

28 Pa. Code 211.5(f) Clinical Records

28 Pa. Code 211.10(d) Resident Care Policies
Previously cited 7/10/20, 5/7/19

28 Pa. Code 211.12(d)(1)(5) Nursing Services
Previously cited 7/10/20,6/18/20, 5/7/19







 Plan of Correction - To be completed: 05/03/2021

Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

All residents receiving PRN Narcotic Pain Medication have the potential to be affected. Resident 54 was assessed for complaints of pain by staff, and physician was made aware of concern.

Administering nurses were immediately educated, as was the alert resident on the importance of using pain scale to report pain level. Administering nurses to notify MD if for requests not within stated parameters.

Pain Management policy was reviewed and revised as needed. In-services were provided to appropriate staff immediately. Facility wide education initiated for professional nurses administering medications.

DON, or designee, will audit for appropriate documentation of Pain Scale related to PRN Narcotic Medication Administration. Audits will occur daily x2 weeks, weekly x2 and monthly x2, on all shifts. If trends are identified, corrective action, including a Root Cause Analysis, will be reported to the QA Committee.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to 483.70(e) and following accepted national standards;

483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:


Based on observation, clinical record review and staff interviews, it was determined that the facility failed to ensure that infection prevention and control was maintained during tracheostomy care on one of two residents reviewed (Resident 250).

Findings include:

A review of Resident 250's diagnoses revealed Respiratory Failure, and Cerebral Infarction (Stroke).

A review of the progress notes dated January 14, 2021, at 6:39 p.m. revealed that Resident 250 was admitted to the facility with a tracheostomy (A surgical procedure that consist of making an incision on the front aspect of the neck and opening a direct airway through an incision in the windpipe). Further review of the same note revealed an order for as-needed suctioning and tracheostomy care every shift.

An observation of the tracheostomy care was conducted on March 11, 2021, at 8:40 a.m. with licensed Employee E8. The observation revealed that after Employee E8 checked Resident 250's oxygen saturation (Measures the number of red blood cells), Employee E8 cleaned the bedside table, removed his gloves, and set up the dressing, gloves, and other things that will be used for suctioning and tracheostomy care. Employee E8 opened a sterile glove package, picked up the sterile gloves with bare hands, stretched it then put them on. Employee E8 used his left hand to touch unsterile areas/surfaces which includes the suction knob while suctioning and used his right hand to touch the suction tube. At 8:52 a.m. Employee E8 used his left hand to insert the tip of the suction tube inside the cannula then proceeded with suctioning the resident. After suctioning, Employee E8 changed gloves, removed the gauze with phlegm on the resident's tracheostomy site then threw it on the garbage receptacle then changed gloves. Employee E8 cleaned the surrounding of the resident's tracheostomy site with gauze, changed gloves then cleaned it again with a Qtip. After changing gloves, Employee E8 picked up the sterile disposable inner cannula and placed it on the resident's tracheostomy then cleaned the phlegm of the tracheostomy mask then placed it on the resident's neck. After changing gloves, Employee E8 rechecked the resident's oxygen saturation, removed all used dressings and packages then performed handwashing.

During the entire observation of suctioning and tracheostomy care, Employee E8 was observed changing gloves a total of six times but did not observed performing any hand hygiene in between changing of the gloves.

An interview was conducted With Employee E8 on March 11, 2021, at 9:00 a.m. and was made aware of contaminating the sterile gloves used for suctioning and the tip of the suction tube. Employee E8 was also made aware of the missed hand hygiene in between changing gloves, the employee acknowledged the surveyor.

The above was conveyed to the Assistant Director of Nursing on March 11, 2021, at 1:00 p.m.

The facility failed to ensure that infection control and prevention were maintained during Resident 250's tracheostomy care.

28 Pa. Code 211.12(d)(1)(5) Nursing Services
Previously cited 7/10/20, 6/18/20, 5/7/19.







 Plan of Correction - To be completed: 05/03/2021

Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

All residents requiring suctioning via an endotracheal tube have the potential to be affected. Regarding resident 250, a full respiratory assessment was conducted. Respiratory assessment, including a full set of vital signs were implements every shift x 72 hours. Physician made aware; Respiratory Therapist was educated.

Tracheostomy policies were reviewed and revised as needed. In-services were provided to appropriate staff immediately. Facility wide education initiated for Respiratory Therapist, professional nurses regarding tracheostomy care, including suctioning and infection control principles.

DON, or designee, will audit for appropriate tracheostomy care, including suctioning. Audits will occur daily x2 weeks, weekly x2 and monthly x2, on all shifts. If trends are identified, corrective action, including a Root Cause Analysis, will be reported to the QA Committee


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